Client Registration Form - San Bruno Pet Hospital

Download and Print Form
All reminders are sent via email.

"*" indicates required fields

Client Information

Name*

First Last

Spouse/Secondary Name

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Best Time To Reach You*

Hours

Minutes

AM/PM

Place of Employment

Email Address*

Name of previous hospital or veterinary clinic*

Does your pet have insurance?*

Yes

Name of Insurance Co:*

How did you become aware of our clinic?*

Location

Google

Yelp

Facebook

Instagram

Personal Recommendation

Whom may we thank?*

Any previous serious illnesses or surgeries?*

Yes

Please list*

Is your pet on any special diets or medications?*

Yes

Please list*

Pet Information

Name*

Species*

Breed*

Date of Birth*

MM slash DD slash YYYY

Color/Markings*

Sex*

Male

Female

Spayed/Neutered*

Yes

Add another pet?

Yes

Pet #2

Name

Species

Breed

Date of Birth

MM slash DD slash YYYY

Color/Markings

Sex

Male

Female

Spayed/Neutered

Yes

Add a third pet?

Yes

Pet #3

Name

Species

Breed

Date of Birth

MM slash DD slash YYYY

Color/Markings

Sex

Male

Female

Spayed/Neutered

Yes

Add a fourth pet?

Yes

Pet #4

Name

Species

Breed

Date of Birth

MM slash DD slash YYYY

Sex

Male

Female

Color/Markings

Spayed/Neutered

Yes

Appointment Information

We want to provide excellent customer service and high quality patient care, and strive to meet and exceed your expectations. The pieces of information on the following page are important topics, and we’d like to be proactive in your wishes. Please don’t hesitate to inquire if you would like further explanation or have questions.

In order to maintain a safe, comfortable environment, we do require all pets to be current on their rabies vaccinations. State law requires that we provide our County’s Animal Care Services a copy of all canine patients who have received a Rabies immunization vaccine.*

Policy Read

We would like you to know that we are not a 24 hour facility, and on occasion there may be pets in the facility in the absence of personnel. Your pet’s doctor will discuss options for overnight care and monitoring when appropriate. Our hospital is equipped with security cameras for your protection.*

Policy Read

We appreciate your help in keeping our schedule running efficiently. If you need to cancel or change an appointment time, please let us know as soon as possible. We require notice at least 12 hours in advance for canceled appointments. If you do not cancel at least 12 hours prior for three separate appointments, there will be a cancellation fee equal to the cost of an examination added to your account balance.*

Policy Read

We understand that delays can occasionally happen; however, we must try our best to keep the doctors on schedule. If a patient arrives more than 10 minutes past their scheduled time, we may have to reschedule your appointment.*

Policy Read

Our hospital utilizes a 3rd party to help remind you about your pet’s current medical needs such as vaccines due. This agency will not provide your personal information to any other party. Please notify us if we do not have permission to send reminders to you.*

Policy Read

We love to share veterinary success stories, testimonials and photos. Please notify us if you wish to prohibit us from using your pet’s photo, and/or testimonial for training, educational and marketing purposes. There is no expectation of financial compensation, and your full name will not be used.*

Policy Read

Many drugs that have been approved for use in humans and/or some animals have also been proven to be safe and effective in species for which the drugs are not labeled. Our veterinarians, often by necessity, must recommend, administer, and prescribe drugs that are considered extra-label. I authorize my pet’s veterinarian to use extra-label drugs.*

Policy Read

Occasionally, we will receive requests from grooming, boarding, day care, or veterinary facilities and will comply upon their request. In the event you’ve notified us your pet is covered by veterinary pet insurance, we will send medical records when requested.*

Policy Read

One of the most effective ways to promote and maintain the health and safety of your pets is by providing a thorough exam and consultation that our veterinarians administer with every vaccine. It is our policy to not give “out patient” vaccines without an examination. The reason for this policy is that we do not want to do anything that may make your pet sick. Also, our patients cannot talk and may hide subtle symptoms of illness, a thorough physical exam is the best way to be sure they are healthy enough to be vaccinated safely. It is also our policy to not give 2 new injectable vaccines within 10 days of each other. By doing this, if your pet does have a vaccine reaction, we will know which one caused it.*

Policy Read

Non-prescription items purchased may be returned within 30 days of purchase for exchange or refund. With original receipt, items will be returned for the full purchase price and refunds will be issued in the original method of payment. For any return, you will be asked for valid photo identification. We reserve the right to limit or refuse a refund. Gift cards, pre-paid cards and phone cards cannot be returned or exchanged (except where required by law). NOTE: This policy does not apply to prescriptions. By law, we cannot accept returns or refunds of prescription products for reuse or resale.*

Policy Read

Age Requirement Notice: Please note that all pet owners scheduling appointments must be at least 18 years old. If the pet owner is under 18, a legal guardian must be present during the appointment to provide consent and assume responsibility.*

Policy Read

Please initial here to acknowledge that you have read the policies above.*

(Initial here)

I agree that all of this information is true and correct, I am at least 18 years of age and I agree to pay for all medical services at the time they are rendered.

Signature*

*By typing in your name into the Signature text box – you are acknowledging and signing this intake form.